Swimmers asthma 7 th, April, 2008 Joseph Cummiskey MD Respiratory Physician Member IOC, MC Consensus...

Swimmers asthmaSwimmers asthma77thth, April, 2008, April, 2008

Joseph Cummiskey MDJoseph Cummiskey MDRespiratory PhysicianRespiratory Physician

Member IOC, MC Consensus meeting on asthma in sportMember IOC, MC Consensus meeting on asthma in sportMember of Task Force of the ERS & EAACI on Diagnosis of asthma in sportMember of Task Force of the ERS & EAACI on Diagnosis of asthma in sport

IOC ASTHMA CONSENSUS CONFERENCE

Outline of my talkOutline of my talk

Definition of asthmaDefinition of asthma

Diagnosis of asthma in elite athletesDiagnosis of asthma in elite athletes

Etiology of asthma in swimmersEtiology of asthma in swimmers

WADA rules in asthma treatmentWADA rules in asthma treatment


Exercise is good for your healthExercise is good for your healthAsthma, exercise and the environmentAsthma, exercise and the environment

Air Quality and Asthma: Air Quality and Asthma: The Summer Outdoor/IndoorThe Summer Outdoor/Indoorand the Winter Indoor Athleteand the Winter Indoor Athlete

DEFINITION DEFINITION of asthma-1of asthma-1

Two main definitions of asthma have been used. Two main definitions of asthma have been used.

The first is the classification of asthma as a The first is the classification of asthma as a manifestation of atopy, thereby including eczema and manifestation of atopy, thereby including eczema and raised levels of IgE in the definition.raised levels of IgE in the definition.

The second approach is by defining asthma in the The second approach is by defining asthma in the form of induced bronchial hyperreactivity, without form of induced bronchial hyperreactivity, without reference to atopy. reference to atopy.

Atopic and non-atopic asthmaAtopic and non-atopic asthma

DEFINITION DEFINITION of asthma-2of asthma-2 Does this mean there are 2 distinct forms of Does this mean there are 2 distinct forms of

asthma involving distinctly different asthma involving distinctly different immunopathological processes?immunopathological processes?

Th 1 type cells express Th 1 type cells express CXC chemokine receptor (CXCR)-3CXC chemokine receptor (CXCR)-3 CC chemokine receptor (CCR)-5CC chemokine receptor (CCR)-5

Th 2 type cells expressTh 2 type cells express CCR3, CCR4, CCR8CCR3, CCR4, CCR8

Mast cells release PGD-2 and LTC-4 and Mast cells release PGD-2 and LTC-4 and histamine that works on the smooth muscle cellshistamine that works on the smooth muscle cells

DEFINITION DEFINITION of asthma-3of asthma-3 We must ask the question early on “do we want to approach asthma We must ask the question early on “do we want to approach asthma

as a single syndrome (lumper) or do we want various forms of as a single syndrome (lumper) or do we want various forms of asthma (splitter)”.asthma (splitter)”. Asthma is phenotypically heterogenousAsthma is phenotypically heterogenous Asthma is a multifaceted diseaseAsthma is a multifaceted disease

Asthma maybe a systemic inflammatory disorder that includes the Asthma maybe a systemic inflammatory disorder that includes the GI tractGI tract

Splitters would saySplitters would sayLymphocyte v eosinophil infiltrate in the airwaysLymphocyte v eosinophil infiltrate in the airways

Should we be using less ICS in neutrophil asthmaShould we be using less ICS in neutrophil asthmaApotosis of leukocytes is blocked by ICSApotosis of leukocytes is blocked by ICS

DEFINITION DEFINITION of asthma-4of asthma-4

Brochoconstriction various with various Brochoconstriction various with various stimulants:stimulants:INDIRECTINDIRECT Exercise, Exercise, EVH, EVH,

DIRECTDIRECT Hypertonic saline, Hypertonic saline, MannitolMannitolMethacholine, bromide v chloride,Methacholine, bromide v chloride,

Response to therapyResponse to therapyICSICSBeta-2 sympathomimeticsBeta-2 sympathomimetics

Diagnosis of Asthma in Elite Diagnosis of Asthma in Elite AthletesAthletes

Respiratory symptoms such as recurrent Respiratory symptoms such as recurrent breathlessness, cough, wheezing, chest breathlessness, cough, wheezing, chest tightness and excessive mucous production are tightness and excessive mucous production are common in athletes and may be suggestive of common in athletes and may be suggestive of asthma. asthma.

As these symptoms alone cannot be relied upon As these symptoms alone cannot be relied upon for making a diagnosis of asthma and clinical for making a diagnosis of asthma and clinical examination may be normal, objective tests are examination may be normal, objective tests are required to confirm the diagnosis. required to confirm the diagnosis.

Diagnosis of Asthma in Elite Diagnosis of Asthma in Elite AthletesAthletes

These tests would include spirometry (forced expiratory volume in These tests would include spirometry (forced expiratory volume in one second FEV1). one second FEV1).

Athletes may have an FEV1 within or above the normal range, this Athletes may have an FEV1 within or above the normal range, this does not exclude variable airway obstruction. does not exclude variable airway obstruction.

If airway obstruction is present, spirometry should be repeated after If airway obstruction is present, spirometry should be repeated after inhalation of a bronchodilator to test for reversibility. inhalation of a bronchodilator to test for reversibility.

In the absence of airflow limitation, a bronchial provocation test, to In the absence of airflow limitation, a bronchial provocation test, to establish the presence of bronchial hyperresponsiveness, is establish the presence of bronchial hyperresponsiveness, is needed. needed.

If the results of these tests are negative other disorders should be If the results of these tests are negative other disorders should be considered. considered.

PFT in asthmaPFT in asthma This clinical syndrome must have the clinical diagnosis This clinical syndrome must have the clinical diagnosis

of asthma supplemented with the addition of of asthma supplemented with the addition of Pulmonary Function Tests (to ERS and / or ATS Pulmonary Function Tests (to ERS and / or ATS standards).standards).

The percentage changes in PFT are as follows The percentage changes in PFT are as follows resting pulmonary function tests, (12% bronchodilation resting pulmonary function tests, (12% bronchodilation

above the predicted or the athletes resting FEV-1)above the predicted or the athletes resting FEV-1) non-pharmacological challenge (10% bronchoconstriction)non-pharmacological challenge (10% bronchoconstriction)

Exercise or Exercise or Eucapnic Voluntary Hyperventilation testsEucapnic Voluntary Hyperventilation tests

pharmacological stimulation tests pharmacological stimulation tests (20% bronchoconstriction at a Methacholine dose of < 4 mg/ml)(20% bronchoconstriction at a Methacholine dose of < 4 mg/ml) (15% bronchoconstriction to a Mannitol test)(15% bronchoconstriction to a Mannitol test) (15% bronchoconstriction to a 4.5% saline challenge)(15% bronchoconstriction to a 4.5% saline challenge)

Environmental aspects of Environmental aspects of asthma in elite athletesasthma in elite athletes

The major environmental factors which could influence The major environmental factors which could influence airway function in elite athletes are allergens and airway function in elite athletes are allergens and ambient conditions such as temperature, humidity and ambient conditions such as temperature, humidity and air quality. air quality.

Because of the high minute ventilation during exercise, the Because of the high minute ventilation during exercise, the effects of these exposures may be more marked in effects of these exposures may be more marked in athletes. athletes.

Exposures of importance to the athlete include seasonal Exposures of importance to the athlete include seasonal and perennial allergens, dry / cold air, chlorine and perennial allergens, dry / cold air, chlorine derivatives in swimming pools, ozone and combustion derivatives in swimming pools, ozone and combustion derived pollutants, such as oxides of nitrogen and derived pollutants, such as oxides of nitrogen and particulate matter.particulate matter.

Etiology of asthma in swimmersEtiology of asthma in swimmers

AtopyAtopyFH, high eosinophil count, high IgE, FH, high eosinophil count, high IgE,

symptoms spontaneously at night and without symptoms spontaneously at night and without provocationprovocation

TrainingTrainingDamage the airwaysDamage the airwaysDamage the lung vasculature esp capillariesDamage the lung vasculature esp capillaries

EnvironmentEnvironmentChoridesChorides

Is sport health damaging ? Is sport health damaging ? – probably – yes !!– probably – yes !!

Training as a cause of Asthma in Training as a cause of Asthma in Elite AthletesElite Athletes

Long-term intense endurance training may be associated with an Long-term intense endurance training may be associated with an increased risk of development of airway hyperresponsiveness and increased risk of development of airway hyperresponsiveness and asthma in the elite athlete.asthma in the elite athlete.

Environmental factors, such as allergens, chlorine derivatives, Environmental factors, such as allergens, chlorine derivatives, pollutants or cold air exposure may contribute to the development of pollutants or cold air exposure may contribute to the development of airway inflammation and functional changes. Their penetration into airway inflammation and functional changes. Their penetration into the airways will be enhanced by the high ventilation required during the airways will be enhanced by the high ventilation required during intense exercise.intense exercise.

The changes in lung function and airway responsiveness may be The changes in lung function and airway responsiveness may be partly reversible after cessation of long-term endurance training. partly reversible after cessation of long-term endurance training.

More research is necessary on how to prevent or minimise the More research is necessary on how to prevent or minimise the adverse effects of long-term training on the airways, particularly the adverse effects of long-term training on the airways, particularly the effects of environmental exposure on airway structure and function.effects of environmental exposure on airway structure and function.

TrainingTraining

Powerful systemic Powerful systemic inflammatory stressinflammatory stress

Multi-organ adaptation (except Multi-organ adaptation (except the lung)the lung)

Pulmonary pressuresPulmonary pressures -I> lung injury-I> lung injury

Transient interstitial edemaTransient interstitial edema

Training as a cause of asthmaTraining as a cause of asthma

Mechanical damage to the airways ? air or Mechanical damage to the airways ? air or exercise exercise

In exercise it may be the pattern of breathing: In exercise it may be the pattern of breathing: rough and deep i.e. trauma to the airwaysrough and deep i.e. trauma to the airways

Exhale against water resistanceExhale against water resistance High lung function (130% predicted volumn and High lung function (130% predicted volumn and

flows)flows) Alveoli are large but not the capillaries, high Alveoli are large but not the capillaries, high

haemoglobinhaemoglobin

CT & MR images of exercise-CT & MR images of exercise-induced Pulmonary Edemainduced Pulmonary Edema

Interstitial edema, peribronchial edema,transient, increased lung water, Interstitial edema, peribronchial edema,transient, increased lung water, only occurs in top athletes, only occurs in top athletes,

? vascular injury? vascular injury

asthmaasthma Weekly swimming in Weekly swimming in

indoor chlorinated indoor chlorinated pools – is associated pools – is associated with increased with increased frequency of asthma frequency of asthma especially among especially among children with a family children with a family history of asthma history of asthma A. Bernard et al. Lung A. Bernard et al. Lung hyperpermeability and asthma hyperpermeability and asthma prevalence in schoolchildren: prevalence in schoolchildren: unexpected associations with the unexpected associations with the attendance at indoor chlorinated pools attendance at indoor chlorinated pools (Occ Envir Med 2003; 60: 385-) 1881 (Occ Envir Med 2003; 60: 385-) 1881 børn i alderen 5-8 år.børn i alderen 5-8 år.

The Pool Chlorine HypothesisThe Pool Chlorine HypothesisThe Pool Chlorine HypothesisThe Pool Chlorine Hypothesis

““rise in childhood asthma results from exposure to rise in childhood asthma results from exposure to chloramines in the air of indoor pools”chloramines in the air of indoor pools”

Nitrogen trichloride (trichloramine)Nitrogen trichloride (trichloramine) Chloramines formed from NH3 + HOClChloramines formed from NH3 + HOCl Probability of developing asthma is strongly linked to Probability of developing asthma is strongly linked to

pool attendance before 6-7 years of age pool attendance before 6-7 years of age (Bernard et al. 2006)(Bernard et al. 2006)

Elevated eNO is strongly associated with indoor pool Elevated eNO is strongly associated with indoor pool attendance attendance (Bernard et al. 2006)(Bernard et al. 2006)

Finnish Olympic swimmers: 36%-79% bronchial Finnish Olympic swimmers: 36%-79% bronchial hyperresponsiveness to methacholine or histamine hyperresponsiveness to methacholine or histamine (Helenius & Haahtela 2000)(Helenius & Haahtela 2000)


A 5 year follow-up study A 5 year follow-up study (Helenius et al. 2002).(Helenius et al. 2002).

Current asthma (bronchial responsiveness & Current asthma (bronchial responsiveness & exercise-induced symptoms) in swimmers exercise-induced symptoms) in swimmers increased during swimming career and increased during swimming career and decreased after stopping.decreased after stopping.

Sputum EOS increased in active swimmers, Sputum EOS increased in active swimmers, tended to decrease in “past swimmers”.tended to decrease in “past swimmers”.


NClNCl33 exposure and oxidative stress exposure and oxidative stress (Varraso et al. 2002)(Varraso et al. 2002)

Plasma GSH-Px activity increasedPlasma GSH-Px activity increased Acts as anti-oxidantActs as anti-oxidant Reduces lipid hydroperoxides to alcohols Reduces lipid hydroperoxides to alcohols

2GSH + H 2GSH + H22OO22 → GSSG + 2H → GSSG + 2H2200

SOD activity increasedSOD activity increased Dismutates superoxide to ODismutates superoxide to O22 & H & H22OO22

Fast rx that out-competes NO (which forms peroxynitrite with Fast rx that out-competes NO (which forms peroxynitrite with OO22

--))

COMEAP statementCOMEAP statement

Suggestive but evidence is insufficentSuggestive but evidence is insufficentNot thr cause of asthma epidemicNot thr cause of asthma epidemicThe least chlorine possible for an The least chlorine possible for an

adequate anti-microbial effectadequate anti-microbial effectFurther research is necessaryFurther research is necessary

WADAWADA

Because of the widespread use and Because of the widespread use and potential for misuse of potential for misuse of

inhaled beta 2 agonists by athletes, inhaled beta 2 agonists by athletes,

there was consensus to continue there was consensus to continue

the strict control of the use of this class of the strict control of the use of this class of drugs in sport.drugs in sport.

WADA rules for asthmaWADA rules for asthma

All beta 2 agonists and in particular oral preparations are All beta 2 agonists and in particular oral preparations are prohibited. prohibited.

Inhaled corticosteroids and some inhaled beta 2 agonists Inhaled corticosteroids and some inhaled beta 2 agonists can be used in accordance with the relevant section of can be used in accordance with the relevant section of

the Therapeutic Use Exemption (TUE) process. the Therapeutic Use Exemption (TUE) process.

Systemic corticosteroids are prohibited and also require a Systemic corticosteroids are prohibited and also require a TUE.TUE.

Thank youThank you

Questions?Questions?

If the chairman wishesIf the chairman wishesIOC ASTHMA CONSENSUS CONFERENCE

DEFINITION DEFINITION of asthmaof asthma

A set of guidelines for A set of guidelines for General Physicians General Physicians Respiratory physiciansRespiratory physicians

Follow-up of asthma and its degree of controlFollow-up of asthma and its degree of control

Clinical ACT asthma control test, correlates well with Clinical ACT asthma control test, correlates well with inflammatory e NOinflammatory e NO

InflammatoryInflammatory e Nitric Oxidee Nitric Oxide

Physiologic FEV-1 correlates poorly with the other 2Physiologic FEV-1 correlates poorly with the other 2

Value of swimmingValue of swimming A program of swimming for asthmaticsA program of swimming for asthmatics No asthma exacerbations in 20 years of swimming in asthmatics.No asthma exacerbations in 20 years of swimming in asthmatics. Majority have asthma after 24 years.Majority have asthma after 24 years. FH was positive for asthmaFH was positive for asthma Endurance sport in summer and winterEndurance sport in summer and winter Symptoms and a positive ahr testSymptoms and a positive ahr test 40-50% active swimmers40-50% active swimmers 12-30% past swimming i.e. some loose it others will not12-30% past swimming i.e. some loose it others will not Super dosing of the pool with chorine was used the night before Super dosing of the pool with chorine was used the night before

weekly training for 20 years.weekly training for 20 years.


Asthmatic children and adolescents (n = 46)Asthmatic children and adolescents (n = 46)

swimming training for five months swimming training for five months

Physical work capacity (PWCPhysical work capacity (PWC170170) treadmill) treadmill

run increased 11% (mean); controls 3.9%run increased 11% (mean); controls 3.9%

Post exercise-induced asthma (runningPost exercise-induced asthma (running

challenge) unchanged; challenge) unchanged;

mean post-exercise decrease in FEVmean post-exercise decrease in FEV11 33% (mean) 33% (mean)

pre-swim training and 32.1% post trainingpre-swim training and 32.1% post trainingIOC ASTHMA CONSENSUS CONFERENCE 2008

Asthmatic children and adolescents Asthmatic children and adolescents

(aged 9 to 16 years: n = 46) (aged 9 to 16 years: n = 46) undertook five months of supervised swimming training.undertook five months of supervised swimming training.

OutcomesOutcomesDecreased asthmaDecreased asthmaReduced medication Reduced medication Increased lung volumes (p < 0.01)Increased lung volumes (p < 0.01)Program fitness in childhood remains thro lifeProgram fitness in childhood remains thro life

Above benefits were proportional to the distance swumAbove benefits were proportional to the distance swumIOC ASTHMA CONSENSUS CONFERENCE 2008

Asthmatic children and adolescents Asthmatic children and adolescents

(aged 9-16 years: n = 46) (aged 9-16 years: n = 46)

undertook five months of supervised swimming training.undertook five months of supervised swimming training.

OutcomesOutcomes

Improved posture (p < 0.01)Improved posture (p < 0.01) Reduced body fat (p <0.05)Reduced body fat (p <0.05)

Increased distance swum in 9 minIncreased distance swum in 9 min Less protecting parentsLess protecting parents

Fitch Morton Blanksby Arch Dis Childh 1976; 51: 190-194Fitch Morton Blanksby Arch Dis Childh 1976; 51: 190-194IOC ASTHMA CONSENSUS CONFERENCE 2008

Elite swimming athletesElite swimming athletes

• 5/7 CDN swimmers + EVH (>20%)5/7 CDN swimmers + EVH (>20%)• Most have no childhood history of Most have no childhood history of

asthma/atopyasthma/atopy• Not consistent symptomatologyNot consistent symptomatology• Many do not feel limited in the poolMany do not feel limited in the pool• Compelling evidence of changes in AHR Compelling evidence of changes in AHR

with timewith time


TreatmentTreatment

Past experience with elite athletesPast experience with elite athletes

Current recommendationsCurrent recommendations

Future recommendationsFuture recommendations

Past experience of beta 2 Past experience of beta 2 agonists use in Elite Athletesagonists use in Elite Athletes

There are good data now available on athletes who seek approval There are good data now available on athletes who seek approval to use a beta 2 agonist. to use a beta 2 agonist.

These data arise from the recent Winter and Summer Olympic These data arise from the recent Winter and Summer Olympic Games and from World IAAF championships in athletics. Games and from World IAAF championships in athletics.

While most applications for the Games came from those competing While most applications for the Games came from those competing in endurance sports this was not a universal finding. in endurance sports this was not a universal finding.

The geographical distribution of the applications closely relates to The geographical distribution of the applications closely relates to the reported prevalence of asthma in those countries. the reported prevalence of asthma in those countries.

Over the last 5 years there has been a significant increase in the Over the last 5 years there has been a significant increase in the proportion of athletes using inhaled corticosteroids in conjunction proportion of athletes using inhaled corticosteroids in conjunction with a beta 2 adrenoceptor agonist. with a beta 2 adrenoceptor agonist.

A minority of athletes are now relying on a beta 2 agonist alone to A minority of athletes are now relying on a beta 2 agonist alone to manage their condition. manage their condition.

Treatment of Asthma in Elite Treatment of Asthma in Elite AthletesAthletes

The management of the athlete with asthma should follow current national The management of the athlete with asthma should follow current national or international guidelines (eg Global INitiative for Asthma-GINA).or international guidelines (eg Global INitiative for Asthma-GINA).

At present, there is no evidence that management of asthma in athletes At present, there is no evidence that management of asthma in athletes should differ from non athletes.should differ from non athletes.

However, some specific issues should be considered for the high-level However, some specific issues should be considered for the high-level athlete.athlete.

The prevention and management of exercise induced bronchoconstriction is The prevention and management of exercise induced bronchoconstriction is a key issue in athletes. a key issue in athletes.

They may also be exposed to high levels of allergens and environmental They may also be exposed to high levels of allergens and environmental irritants during training and competition because of high ventilation rates. irritants during training and competition because of high ventilation rates. Dry/cold air may be a particular problem for some athletes. Dry/cold air may be a particular problem for some athletes.


Athletes should be offered Asthma education in order to develop Athletes should be offered Asthma education in order to develop self management skills and ensure appropriate use of medication self management skills and ensure appropriate use of medication including inhaler technique. including inhaler technique.

Individualised action plans for the management of exacerbations, Individualised action plans for the management of exacerbations, asthma monitoring and follow-up are important.asthma monitoring and follow-up are important.

The non-pharmacological management of asthma in athletes is The non-pharmacological management of asthma in athletes is important. important.

This includes identifying and avoiding asthma triggers whenever This includes identifying and avoiding asthma triggers whenever possible and especially during training. possible and especially during training.

Warm-up may help to reduce exercise-induced bronchoconstriction.Warm-up may help to reduce exercise-induced bronchoconstriction.


Drug treatment of asthma in athletes should Drug treatment of asthma in athletes should follow standard guidelines: treatment should be follow standard guidelines: treatment should be individualised to achieve asthma control.individualised to achieve asthma control.

The effects of treatment should be monitored. The effects of treatment should be monitored.

Any medications prescribed should comply with Any medications prescribed should comply with World Anti-Doping Agency (WADA) regulations.World Anti-Doping Agency (WADA) regulations.


Inhaled corticosteroids are the most Inhaled corticosteroids are the most effective drugs for long term control and effective drugs for long term control and

prevention of asthma and EIB.prevention of asthma and EIB.



Inhaled beta 2 agonists are the most effective drugs for immediate inhibition of Inhaled beta 2 agonists are the most effective drugs for immediate inhibition of exercise-induced bronchoconstriction (EIB) and for relieving intermittent symptoms of exercise-induced bronchoconstriction (EIB) and for relieving intermittent symptoms of asthma. asthma.

However, tolerance (or tachyphylaxis) to the effects of beta agonists develops rapidly However, tolerance (or tachyphylaxis) to the effects of beta agonists develops rapidly when used frequently. when used frequently.

Athletes who use short- or long-acting beta-agonists on a daily basis should be advised that Athletes who use short- or long-acting beta-agonists on a daily basis should be advised that their effectiveness to prevent EIB will partially diminish. their effectiveness to prevent EIB will partially diminish.

Frequent use of beta-agonists may also increase the bronchoconstrictor response to Frequent use of beta-agonists may also increase the bronchoconstrictor response to exercise and allergens. exercise and allergens.

Strategies to avoid these problems could include restricting beta-agonists to infrequent use, Strategies to avoid these problems could include restricting beta-agonists to infrequent use, use of alternative treatments for preventing exercise-induced bronchoconstriction and use of alternative treatments for preventing exercise-induced bronchoconstriction and ensuring adequate treatment of underlying asthma with inhaled corticosteroids.ensuring adequate treatment of underlying asthma with inhaled corticosteroids.

Long acting beta agonists should never be used as monotherapy.Long acting beta agonists should never be used as monotherapy.

Future of beta 2 agonists in elite Future of beta 2 agonists in elite athletesathletes

Beta 2 agonists are likely to remain the most effective Beta 2 agonists are likely to remain the most effective bronchodilators available in the foreseeable future. bronchodilators available in the foreseeable future.

However, they may have a less important role in the management of However, they may have a less important role in the management of asthma because exercise induced bronchoconstriction should be asthma because exercise induced bronchoconstriction should be better controlled by use of other therapies such as ICS, LT better controlled by use of other therapies such as ICS, LT inhibitors, chromates and monoclonal antibodies against IgE.inhibitors, chromates and monoclonal antibodies against IgE.

Such therapies are likely to target the production, release and Such therapies are likely to target the production, release and effects of the mediators of bronchoconstriction. effects of the mediators of bronchoconstriction.

Ideally, beta agonists should be reserved for occasional use and Ideally, beta agonists should be reserved for occasional use and breakthrough symptoms. Better strategies to avoid the development breakthrough symptoms. Better strategies to avoid the development of beta 2 agonists tolerance need to be developed. of beta 2 agonists tolerance need to be developed.

History of Beta - 2 Sympathomimetics History of Beta - 2 Sympathomimetics at the Olympic Gamesat the Olympic Games

Pre-1972Pre-1972 AllowedAllowed

19721972 ProhibitedProhibited

1976-’841976-’84 Permitted with notificationPermitted with notification

1988-921988-92Not necessary to reportNot necessary to report

1996-20001996-2000 Permitted with notificationPermitted with notification

2002-20062002-2006 Application reviewed by an Application reviewed by an international independent international independent panelpanel

20062006 On a specified listOn a specified list

Most commonly used, allowed if Most commonly used, allowed if notified, drug in sportnotified, drug in sport

Rising Prevalence of use of anti-asthma drugs Rising Prevalence of use of anti-asthma drugs in all competing athletesin all competing athletes

ApplicationsApplications Approved Approved

LALA (1980)(1980) 1.7%1.7% 1.7%1.7% Atlanta Atlanta (1996)(1996) 3.6%3.6% 3.6%3.6% NaganoNagano (1998)(1998) 5.6%5.6% 5.6%5.6% SydneySydney (2000)(2000) 5.7%5.7% 5.7%5.7% SLCSLC (2002)(2002) 6.3%6.3% 5.2%5.2% AthensAthens (2004)(2004) 4.6%4.6% 4.2%4.2% TurinoTurino (2006)(2006) 8.4%8.4% 7.8%7.8%

Where have we come fromWhere have we come from 19991999 The 3 IOC, MC premises highlightedThe 3 IOC, MC premises highlighted 20012001 WADA aTUE for asthmaWADA aTUE for asthma 20022002 International panel at an Olympic GamesInternational panel at an Olympic Games 20042004 Preregistration of use ofPreregistration of use of sympathomimetics sympathomimetics

(stimulants)(stimulants) 20052005 European Academic Respiratory Physician European Academic Respiratory Physician

input in ERS and EAACI article input in ERS and EAACI article (ERS (ERS monograph, monograph, vol 10, no.33, Nov 2005) vol 10, no.33, Nov 2005)

20062006 EOC, MC publish a one page diagnostic criteriae for EOC, MC publish a one page diagnostic criteriae for asthmaasthma

20062006 The above published articles quoted by WADA and The above published articles quoted by WADA and IOC, IOC, MC associated paper MC associated paper

20072007 Interfederal FIMS sports consultationInterfederal FIMS sports consultation 20072007 Presentation of the above papers at FIMS, ECSS, Presentation of the above papers at FIMS, ECSS,

National and other International meetings National and other International meetings with with good feedback on the criteria for asthma good feedback on the criteria for asthma

diagnosisdiagnosis 20082008 IOC, MC consensus statementIOC, MC consensus statement

Prior to 1999Prior to 1999

History from 2001History from 2001

Consensus meeting 2008Consensus meeting 2008

Swimmers asthma 7 th, April, 2008 Joseph Cummiskey MD Respiratory Physician Member IOC, MC Consensus...

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